What is the evidence for use of beta blockers preop for oral maxicillofacial surgery?

Comment by InpharmD Researcher

Evidence for the use of beta blockers for oral maxillofacial surgery in the preoperative setting supports the continuity of chronic therapy. Current preoperative guidelines recommend continuing beta-blockers in patients already receiving them, while new initiation should occur well in advance of surgery (ideally >1 week to 30 days) with careful titration to balance benefits against risks. Given the high prevalence of hypertension in surgical patients and the association between prolonged intraoperative hypotension and adverse outcomes such as myocardial injury, stroke, and death, it is critical that perioperative blood pressure is carefully managed.

Background

According to the 2024 American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guideline for Perioperative Cardiovascular Management for Noncardiac Surgery, for patients on stable doses of beta-blockers undergoing non-cardiac surgery (NCS), it is recommended to continue the use of beta-blockers throughout the perioperative period, unless clinical circumstances dictate otherwise. This approach ensures the management of potential cardiovascular risks associated with the surgical process, maintaining hemodynamic stability and reducing perioperative cardiac events. The decision to proceed with beta-blocker therapy should be tailored to individual patient needs and specific clinical situations encountered during the perioperative period. In patients scheduled for elective non-cardiac surgery (NCS) who have a new indication for beta-blockade, it is advised to start beta blockers well in advance of surgery, preferably more than 7 days before the procedure. This allows sufficient time for evaluating tolerability and adjusting the drug dosage if necessary. There is a notable recommendation against the initiation of beta blockers on the day of surgery for patients without an immediate need for them. This is based on evidence indicating an increased risk of postoperative mortality when beta blockers are started on the day of surgery. [1]

A 2024 narrative review offers a comprehensive synopsis, including valuable reference tables, on the updated preoperative optimization guidelines focused on anticoagulation, antiplatelet therapy, antihypertensive management, and glycemic control. Hypertension is notably the most common diagnosis in surgical patients, with approximately 60% of individuals over the age of 60 affected. For oral and maxillofacial surgeons, the management of both hypotensive and hypertensive episodes is crucial. In the context of general anesthesia, a significant consideration is the direct relationship between prolonged periods of intraoperative hypotension and an increased risk of adverse outcomes such as death, stroke, or myocardial injury following noncardiac surgery. This emphasizes the critical importance of carefully monitoring and managing blood pressure during surgical procedures to mitigate these serious risks. [2]

Another 2024 systematic review and meta-analysis examined the impact of perioperative beta-blocker use in patients undergoing non-cardiac surgery. The study incorporated randomized controlled trials, cohort studies, and case-control studies, encompassing data from 28 studies with a total of 1,342,430 patients. The goal was to assess the effects of beta-blockers on mortality, myocardial infarction (MI), stroke, and other adverse effects, including hypotension and bradycardia, in the perioperative setting. The findings revealed that perioperative beta-blocker use was associated with a statistically significant increase in stroke risk, with a relative risk (RR) of 1.42. However, no significant association was observed between beta-blocker use and mortality or myocardial infarction (MI) rates across the full population studied. Subgroup analysis indicated a protective effect for mortality in high-risk patient groups, such as those with a history of atrial fibrillation or chronic heart failure. On the adverse effects front, beta-blockers were significantly linked to increased risks of hypotension (RR 1.46) and bradycardia (RR 2.26), highlighting the importance of careful patient selection and monitoring. These results underscore the complexity of using beta-blockers in the perioperative period, emphasizing the necessity of tailored patient management to optimize benefits and mitigate risks. [3]

A 2010 editorial delved into the contrasting guidelines on perioperative beta-blockade from the European Society of Cardiology (ESC) and the American College of Cardiology Foundation/American Heart Association (ACCF/AHA). The editorial critically evaluated the recommendations made by these organizations in light of the PeriOperative Ischemia Study Evaluation Trial (POISE), which was the largest randomized controlled trial in perioperative medicine at that time. POISE's findings indicated that while perioperative beta-blockade could decrease cardiac risks, it also increased the risk of all-cause mortality and disabling stroke. The editorial highlighted that both sets of guidelines agree on the continuation of beta-blockers for patients already on chronic treatment and stress the need for titration of beta-blockers according to heart rate and blood pressure. However, differences are evident in the interpretation and recommendations for different patient groups, with the ESC being more inclusive in their recommendations compared to the more restrictive ACCF/AHA guidance. The editorial also discussed the practical implications of these guidelines, particularly concerning the timing of starting beta-blockers and the challenges they impose. It recommended initiating treatment optimally 30 days or at least a week before surgery, followed by careful titration, which could necessitate several preoperative clinic visits. The editorial underscored the importance of balancing the benefits and risks associated with perioperative beta-blockade, especially given the increased risk of adverse outcomes like stroke highlighted by POISE. Furthermore, it emphasized the necessity for careful assessment and management in patients at high cardiac risk and recommended that future practices should strengthen preoperative assessment clinics to ensure safe initiation and monitoring of beta-blocker therapy. [4]

References: [1] Writing Committee Members, Thompson A, Fleischmann KE, Smilowitz NR, et al. 2024 AHA/ACC/ACS/ASNC/HRS/SCA/SCCT/SCMR/SVM guideline for perioperative cardiovascular management for noncardiac surgery: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol. 2024;84(19):1869-1969. doi:10.1016/j.jacc.2024.06.013
[2] Allyn S, Bentov N, Dillon J. Perioperative Optimization and Management of the Oral and Maxillofacial Surgical Patient: A Narrative Review on Updates in Anticoagulation, Hypertension and Diabetes Medications. J Oral Maxillofac Surg. 2024;82(3):364-375. doi:10.1016/j.joms.2023.11.015
[3] Herrera Hernández D, Abreu B, Xiao TS, et al. Beta-Blocker Use in Patients Undergoing Non-Cardiac Surgery: A Systematic Review and Meta-Analysis. Med Sci (Basel). 2024;12(4):64. Published 2024 Nov 11. doi:10.3390/medsci12040064
[4] Sear JW, Foex P. Recommendations on perioperative beta-blockers: differing guidelines: so what should the clinician do?. Br J Anaesth. 2010;104(3):273-275. doi:10.1093/bja/aeq007
Literature Review

A search of the published medical literature revealed 1 study investigating the researchable question:

What is the evidence for use of beta blockers preop for oral maxicillofacial surgery?

Level of evidence

C - Multiple studies with limitations or conflicting results  Read more→


Please see Table 1 for your response.

 

Efficacy and Safety of Oral Propranolol Premedication to Reduce Reflex Tachycardia During Hypotensive Anesthesia With Sodium Nitroprusside in Orthognathic Surgery: A Double-Blind Randomized Clinical Trial
Design

Prospective, randomized, double-blind, placebo-controlled study

N= 60
Objective To determine whether premedication with oral propranolol 10 mg before hypotensive anesthesia with sodium nitroprusside could reduce reflex tachycardia, the amount of sodium nitroprusside used, and blood loss during hypotensive anesthesia for orthognathic surgery
Study Groups

Propranolol group (n= 30)

Control group (n= 30)
Inclusion Criteria Healthy patients with physical status I according to the classification of the American Society of Anesthesiologists, undergoing bimaxillary surgery
Exclusion Criteria Patients with renal, hepatic, cardiac, asthmatic, hematologic, or endocrine disease
Methods

Patients were randomly assigned to receive either 10 mg of propranolol (P group) or a placebo (C group) by a nurse anesthetist 30 minutes before anesthesia induction. The anesthesiologist and patients were blinded to group assignments. Preoperative assessments included complete blood count, urinalysis, chest X-ray, and tests for hepatitis B and HIV antibodies. Participants were instructed to fast for 8 hours prior to the procedure.

Anesthesia followed a standardized technique using intravenous induction with sodium thiopental or propofol, fentanyl, and nasotracheal intubation with pancuronium. Maintenance of anesthesia involved nitrous oxide in oxygen, sevoflurane, fentanyl, and pancuronium, with ventilation adjusted to maintain end-tidal carbon dioxide tension between 35 and 40 mm Hg. Patients were positioned at a 15° head-up angle, with intraoperative monitoring including electrocardiography, end-tidal carbon dioxide, and pulse oximetry.

Blood pressure was measured frequently using the oscillometric technique, deemed safe for induced hypotensive anesthesia. Controlled hypotension commenced at incision with sodium nitroprusside (SNP) titration to achieve a mean arterial pressure (MAP) of 65 to 75 mm Hg, with MAP and heart rate recorded every 5 minutes and urine output hourly. SNP was tapered off following surgical completion, while rebound hypertension and intraoperative blood loss were recorded. Adverse events like cardiac arrhythmias, bradycardia, or sustained hypotension were monitored throughout the intraoperative and postoperative periods.
Duration Not specified
Outcome Measures

Primary: Reduction in reflex tachycardia and amount of sodium nitroprusside used

Secondary: Blood loss during hypotensive anesthesia
Baseline Characteristics   C Group (n= 30) P Group (n= 30) P Value
Female 19 19
Age (yr) 26.30 ± 4.69 24.63 ± 3.71 0.13
Body weight (kg) 55.67 ± 10.63 55.57 ± 10.36 0.97
Baseline SBP (mm Hg) 114.60 ± 8.25 113.10 ± 13.04 0.59
Baseline MAP (mm Hg) 84.37 ± 7.76 84.20 ± 9.99 0.94
Baseline HR (beats/min) 78.50 ± 12.33 78.50 ± 10.56 1
Operative time (min) 283.50 ± 59.04 299.83 ± 58.77 0.29
Hypotensive time (min) 184.70 ± 52.51 197.34 ± 55.33 0.28
Results   C Group (n= 30) P Group (n= 30) P Value
Before SNP infusion - MAP (mm Hg) 90.33 ± 11.05 87.80 ± 10.62 0.37
Before SNP infusion - HR (beats/min) 92.83 ± 12.86 78.33 ± 12.41 0.00
During SNP infusion - MAP (mm Hg) 69.07 ± 4.69 69.80 ± 5.48 0.58
During SNP infusion - HR (beats/min) 101.61 ± 13.87 81.24 ± 8.90 0.00
SNP used (\u03bcg/kg/min) 2.47 ± 1.81 1.31 ± 0.68 0.002
Blood loss (mL) 783.33 ± 438.32 793.33 ± 329.51 0.92
Adverse Events No clinically significant complications were observed in either group. Two patients in the propranolol group had a heart rate of less than 50 beats/minute during the postoperative period, but their blood pressure remained within the normal limit, requiring no intervention. 
Study Author Conclusions Premedication with oral propranolol 10 mg before hypotensive anesthesia with sodium nitroprusside is safe and effective to reduce reflex tachycardia and the amount of sodium nitroprusside used. 
Critique The study was well-designed as a double-blind, randomized clinical trial, which strengthens the validity of the findings. However, the study was limited by its small sample size and the exclusion of patients with certain comorbidities, which may limit the generalizability of the results to a broader population. Additionally, the study did not explore the long-term effects of propranolol premedication in this setting. 
References:
[1] [1] Apipan B, Rummasak D. Efficacy and safety of oral propranolol premedication to reduce reflex tachycardia during hypotensive anesthesia with sodium nitroprusside in orthognathic surgery: a double-blind randomized clinical trial. J Oral Maxillofac Surg. 2010;68(1):120-124. doi:10.1016/j.joms.2009.07.065